The document outlines the risks and safety measures related to radiation exposure for practicing anesthesiologists, emphasizing the importance of understanding radiation characteristics, biological effects, and safety protocols. It highlights the significant occupational radiation exposure anesthesiologists face, especially during fluoroscopic procedures, and stresses the need for education on radiation safety practices and personal monitoring. Recommendations include adhering to the ALARA principle, utilizing protective equipment, and continuously updating knowledge on radiation protection.

1. RADIATION EXPOSURE IN
RADIATION EXPOSURE IN
PRACTICING
PRACTICING
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS
DR SANTOSH KR SHARMA
DR SANTOSH KR SHARMA
ASSISTANT PROFFESOR
ASSISTANT PROFFESOR
DEPT OF ANAESTHESIOLOGY
DEPT OF ANAESTHESIOLOGY
BRD MEDICAL COLLEGE
BRD MEDICAL COLLEGE
GORAKHPUR
GORAKHPUR

2. UNDERSTANDING RADIATION
UNDERSTANDING RADIATION

3. ATOMIC
ATOMIC
RADIATION
RADIATION
FALL OUTS
FALL OUTS

4. RADIATION AFTER EFFECTS
RADIATION AFTER EFFECTS

5. OUTLINE
OUTLINE
1. Characteristics of radiation
2. Units and Quantities
3. Biological Effects of Ionizing Radiation
4. Safe Maximal Radiation Doses
5. Minimizing Radiation Exposure - ALARA
6. Radiation Safety Measures
7. Monitoring

6. THE PROBLEM
THE PROBLEM
 Radiation extensively being used for diagnostic and
therapeutic procedures
 Approx. 3.3 billion of 5 billion imaging examinations
worldwide use ionizing radiation
 There is increased patient visits and patients with
multiple challenging co-morbidities for which
anesthesiologists are increasingly being required
 Fluoroscopic procedures are the largest source of
occupational radiation exposure in medicine including
anaesthesia

7. POINTS OF RADIATION
POINTS OF RADIATION
EXPOSURE IN
EXPOSURE IN
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS

9. EVIDENCES AND FACTS OF
EVIDENCES AND FACTS OF
RADIATION EXPOSURE IN
RADIATION EXPOSURE IN
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS
 One of the earliest articles on the damaging effects of radiation
exposure in anaesthetists was published in 1958 by Kincaid
 Otto & Davidson studied the exposure of nurse anaesthetists
during specific ureteroscopic fluoroscopy procedures in urology
and found the exposure greater than the recommended limits
especially in the area of the thyroid but not for the lens
 S. Ismail & F. A. Khan studied the average exposure to radiation
in trainee anaesthesiologists

10. EVIDENCES AND FACTS OF
EVIDENCES AND FACTS OF
RADIATION EXPOSURE IN
RADIATION EXPOSURE IN
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS
 Henderson et al. found higher radiation exposure in
anaesthetists in the cardiac catheterization laboratory
 The anesthesiologist is exposed to radiation six times
more than other persons during the neuro interventional
angiographic procedures.
 There was doubling of radiation exposure to anesthesia
personnel in the year following the opening of an
electrophysiology laboratory

11. EVIDENCES AND FACTS OF
EVIDENCES AND FACTS OF
EXPOSURE IN
EXPOSURE IN
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS
 Anastasian et. al. demonstrated that the eye may be most sensitive
to radiation damage and dose to anesthesiologist’s eye can be upto
3 times greater than that to the radiologist.
 Anaesthetists can’t distance from young children and sicker
patients when anaesthesia is being administered.
 Anesthesiologist are sometimes a part of disaster management
such as the Chernobyl and Fukushima nuclear hazard
 The workload and complexity of procedures have increased over
the years, meaning a larger cumulative exposure during ones
carrier.

12. RADIATION EXPOSURE
RADIATION EXPOSURE
HAS BECOME A
HAS BECOME A
POTENTIAL HAZARD
POTENTIAL HAZARD
FOR
FOR
ANAESTHESIOLOGISTS
ANAESTHESIOLOGISTS

13. THE KNOWLEDGE GAP
THE KNOWLEDGE GAP
Few can recall specific risks,
dosages, or radiation safety
practices.
Fewer are taught or can recall
being taught these basics as
part of their core curriculum
in anesthesia education

14. THE KNOWLEDGE GAP ?
THE KNOWLEDGE GAP ?
 Anaesthesiologists should not rely on allied medical
professionals to protect themselves and their patients from
harm and should
 be aware of, and comply with the regulations
 understand the physical principles
 make the most effective use of the equipment
 acknowledge that the effects of radiation exposure are
cumulative and permanent
 ensure exposure is kept as low as reasonably acceptable
(ALARA philosphy)
 know methods to minimize the deleterious effects of exposure

15. CHARACTERISTICS
CHARACTERISTICS
OF RADIATION
OF RADIATION

16. 16
THE ELECTROMAGNETIC SPECTRUM
THE ELECTROMAGNETIC SPECTRUM
WAVEFORM OF RADIATION
WAVEFORM OF RADIATION
NONIONIZING IONIZING
Radio
Microwaves
Infrared
Visible light
Ultraviolet
X-rays
Gamma rays

17. IONIZING Vs NONIONIZING RADIATION
IONIZING Vs NONIONIZING RADIATION
 Ionizing radiation
Has enough energy to break
apart (ionize) matter with which it
comes in contact
(remove an electron from matter)
CAN CAUSE CELLULAR INJURY
 Non ionizing radiation
Cannot remove an electron from
matter
MOSTLY HARMLESS

18. FOUR PRIMARY TYPES OF IONIZING
FOUR PRIMARY TYPES OF IONIZING
RADIATION
RADIATION
Alpha particles
Beta particles
Gamma rays
X-Rays
Ionizing Radiation
alpha particle
beta particle
Radioactive Atom
X-ray
gamma ray

19. NON-IONIZING RADIATION FROM
NON-IONIZING RADIATION FROM
HIGH TO LOW FREQUENCY
HIGH TO LOW FREQUENCY

20. WHAT ARE WE NOT TALKING ABOUT?
WHAT ARE WE NOT TALKING ABOUT?
NON-IONIZING RADIATION
NON-IONIZING RADIATION

21. MEDICAL IONIZING RADIATION
MEDICAL IONIZING RADIATION
 Greatest source of artificial
radiation
 Medical radiation exposure
may occur from three
sources:
– Direct exposure from primary x-
ray beam
– Scattered radiation from patient
body surface
– Radiation emitted from leakage of
x-rays

22. SCATTERED RADIATION
SCATTERED RADIATION
During fluoroscopy, radiation
During fluoroscopy, radiation
is scattered from the surface
is scattered from the surface
of the patient where the x-ray
of the patient where the x-ray
beam enters
beam enters
Scattered radiation is the
Scattered radiation is the
main source
main source of radiation dose
of radiation dose
to anaesthesiologist. It also
to anaesthesiologist. It also
decreases image contrast and
decreases image contrast and
degrades image quality.
degrades image quality.
x-ray tube
Detector/Image Intensifier

23. RADIATION UNITS
RADIATION UNITS
Units are Cool

24. DEFINITIONS
DEFINITIONS
 Exposure R (roentgen): Amount of charge produced per unit mass
of air from x-rays and gamma rays.
 Absorbed Dose (rad): Amount of Energy deposited per unit mass
of material. 1Gy = 100 rad.
 Dose Equivalent (rem): Risk adjusted absorbed dose. The
absorbed dose is weighted by the radiation type and tissue
susceptibility to biological damage. 1 Sv = 100 rem.
 Equivalent Dose = Absorbed Dose × wR
 Radiation weighting factors: alpha(20), beta(1), n(10).
 Tissue weighting factors: lung(0.12), thyroid(0.03), and
gonads(0.25)
For whole body x or gamma-ray exposure 1 R  1 rad
 1 rem

25. RADIATION BIOLOGY

26. IONIZATION EFFECTS
IONIZATION EFFECTS
 Direct- Causes breaks
in one or both DNA
strands or
 Indirect- Causes Free
Radical formation

27. 3 CELLULAR EFFECTS
3 CELLULAR EFFECTS
 Rapidly dividing cells are the most radiosensitive
Cell death
Cell repair
Cell change
Is this change good or bad?

28. BIOLOGICAL EFFECTS
BIOLOGICAL EFFECTS
 STOCHASTIC/ PROBABILISTIC
STOCHASTIC/ PROBABILISTIC
 The principal hazard from ionizing medical radiation
 The probability of occurrence of effect depends on dose
 Severity is independent of absorbed dose
 There is no
no threshold
 There is no safe dose below which such an effect cannot occur
 Result when irradiated cells are modified rather than killed.
 Examples of stochastic effects are cancer
cancer and genetic defects
genetic defects.
 Cancer risk is ~ 0.00008% per millirem effective dose.

29. BIOLOGICAL EFFECTS
BIOLOGICAL EFFECTS
 DETERMINISTIC EFFECTS
 a threshold or minimum dose necessary
 No effect occurs below threshold
 Beyond the threshold, severity of injury increases with
dose
 Examples (doses given as absorbed dose)
– Skin erythema : 2-5 Gy
– Irreversible skin damage : 20-40 Gy
– Hair loss : 2-5 Gy
– Sterility : 2-3 Gy
– Cataract : 5 Gy
– Letality (whole body) : 3-5 Gy
– Fetal abnormality : 0.1-0.5 Gy

30. GENETIC DEFECTS
GENETIC DEFECTS
 No direct evidence of
radiation-induced genetic
effects in humans, even at
high doses.
 Rate of genetic disorders
produced in humans is
expected to be extremely low

31. MAXIMUM SAFE DOSE
MAXIMUM SAFE DOSE
LIMITS
LIMITS

32. ANNUAL OCCUPATIONAL DOSE LIMITS
ANNUAL OCCUPATIONAL DOSE LIMITS
Whole Body 5,000 mrem/year
Lens of the eye 15,000 mrem/year
Extremities, skin, and
individual tissues
50,000 mrem per year
Minors 500 mrem per year (10%)
Embryo/fetus* 500 mrem per 9 months
General Public 100 mrem per year
* Declared Pregnant Woman

33. RADIATION SAFETY
RADIATION SAFETY

34. RADIATION PROTECTION STANDARDS
RADIATION PROTECTION STANDARDS
 These standards are laid down globally by the International
Commission on Radiological Protection (ICRP)
 In USA guidelines are based on the National Council on
Radiation Protection and Measurements (NCRP)
 In India, Radiation Protection Rule (RPR) specify general
principles and criteria for radiation protection in handling
radiation sources.
 Atomic Energy Regulatory Board (AERB) issues
guidelines on radiological protection and controlling
radiological safety issues

35. ALARA
ALARA
AS LOW AS REASONABLY ACHIEVABLE
AS LOW AS REASONABLY ACHIEVABLE
 means making every reasonable effort to maintain exposures to
radiation as far below the dose limits as is practicable consistent
with the purpose for which the licensed activity is undertaken,
 taking into account the state of technology,
 the economics of improvements in relation to the state of
technology,
 the economics of improvements in relation to benefits to the
public health and safety,
 and other societal and socioeconomic considerations,
 and in relation to utilization of nuclear energy and licensed
materials in the public interest

36. RADIATION GOSPEL
RADIATION GOSPEL
Although clinician radiation dose is much
Although clinician radiation dose is much
lower than the patient dose, it is proportional
lower than the patient dose, it is proportional
to patient dose.
to patient dose.
Higher patient doses will usually lead to
Higher patient doses will usually lead to
higher operator and staff doses.
higher operator and staff doses.

37. RADIATION PROTECTION STRATAGIES
RADIATION PROTECTION STRATAGIES
1.
1. DECREASE TIME
DECREASE TIME
2.
2. INCREASE DISTANCE
INCREASE DISTANCE
3.
3. INCREASE SHIELDING
INCREASE SHIELDING
4.
4. EDUCATION
EDUCATION
5.
5. MONITORING
MONITORING
RADIATION
TRAINING
PROGRAM

38. TIME
TIME
 Radiation dose is directly proportional to
the time of exposure
 Radiation is only produced when the
beam is on!
 The use of appropriate techniques such
as short bursts of fluoroscopic time
should be mandatory.
 The idea is to keep the screening time to
the minimum necessary.

39. TIME
TIME
 It remains a challenge for teaching
institutions to reduce the fluoroscopic
time while maintaining the quality of
education.
 One of the possible solutions may be
to prepare the trainees before they are
allowed to perform a procedure in
simulated situations.

40. DISTANCE
DISTANCE

41. DISTANCE
DISTANCE
 Inverse Square Law
Inverse Square Law
Radiation intensity is
inversely
proportional to the
distance squared
d1 d2
I1 I2
I1
I2
d2
2
d1
2
=
Mehlmann et al. reported that exposure is minimal at a distance of more than 36 inches.

42. DISTANCE: C-ARM POSITION
DISTANCE: C-ARM POSITION
Position the X-ray tube
Position the X-ray tube
underneath the patient, not
underneath the patient, not
above the patient.
above the patient.
The greatest amount of scatter
The greatest amount of scatter
radiation is produced where
radiation is produced where
the x-ray beam enters the
the x-ray beam enters the
patient.
patient.
By positioning the x-ray tube
By positioning the x-ray tube
below the patient, you receive
below the patient, you receive
less scatter radiation.
less scatter radiation.
X-ray Tube
Image Intensifier

43. DISTANCE: C-ARM POSITION
DISTANCE: C-ARM POSITION
For lateral and oblique
For lateral and oblique
projections, position the
projections, position the
C-arm so that the x-ray
C-arm so that the x-ray
tube is on the opposite
tube is on the opposite
side of the patient from
side of the patient from
where you are working.
where you are working.
This will reduce the
This will reduce the
scatter radiation reaching
scatter radiation reaching
you.
you.
Always stand closer to the
detector/image intensifier.
Always stand farther from the X-Ray
Tube.

45. DISTANCE: C-ARM POSITION
DISTANCE: C-ARM POSITION
Position the x-ray tube and
Position the x-ray tube and
image intensifier so you are
image intensifier so you are
working on the image
working on the image
intensifier side of the patient.
intensifier side of the patient.
Position the x-ray tube as far
Position the x-ray tube as far
from the patient as possible.
from the patient as possible.
Position the Image intensifier
Position the Image intensifier
as close to the patient as
as close to the patient as
possible.
possible.
X-ray tube Image intensifier

46. DISTANCE: PROXIMITY TO THE X-RAY TUBE
DISTANCE: PROXIMITY TO THE X-RAY TUBE
The patient’s skin should never
The patient’s skin should never
touch or be near the x-ray tube
touch or be near the x-ray tube
port (where the x-rays come out).
port (where the x-rays come out).
you should also never touch or be
you should also never touch or be
near the x-ray tube port.
near the x-ray tube port.
Burns can occur in seconds if skin
Burns can occur in seconds if skin
is touching or near the x-ray tube
is touching or near the x-ray tube
port.
port.
X-ray tube port

47. DISTANCE: MINIMIZE THE AIR GAP
DISTANCE: MINIMIZE THE AIR GAP
Move the detector or
Move the detector or
image intensifier as
image intensifier as
close to the patient as
close to the patient as
possible.
possible.
A smaller air gap
A smaller air gap
reduces radiation dose
reduces radiation dose
to the patient and staff
to the patient and staff
and improves image
and improves image
quality.
quality.

48. DISTANCE: STAY OUT OF THE
DISTANCE: STAY OUT OF THE
FLUOROSCOPY BEAM
FLUOROSCOPY BEAM
Don’t put your hands in the fluoroscopy beam unless absolutely
Don’t put your hands in the fluoroscopy beam unless absolutely
necessary for the procedure.
necessary for the procedure.
This is the hand of a
This is the hand of a
physician who was
physician who was
exposed to repeated small
exposed to repeated small
doses of x-ray radiation
doses of x-ray radiation
for 15 years. The skin
for 15 years. The skin
cancer appeared several
cancer appeared several
years after his work with
years after his work with
x-rays had ceased.
x-rays had ceased.
Meissner, William A. and Warren, Shields: Neoplasms, In Anderson W.A.D. editor;
Pathology, edition 6, St. Louis, 1971, The C.V. Mosby Co

49. SHIELDING
SHIELDING
 Materials “absorb” radiation
 Proper shielding =Less Radiation
Exposure

50. ROOM SHIELDING
ROOM SHIELDING
Lead lined plaster board
Lead glass viewing window

51. PERSONAL SHIELDING
PERSONAL SHIELDING

52. SHIELDING: HANG LEAD APRONS PROPERLY
SHIELDING: HANG LEAD APRONS PROPERLY
Hanging lead aprons on
Hanging lead aprons on
hangers/hooks prevents
hangers/hooks prevents
the lead from cracking
the lead from cracking
and tearing.
and tearing.
This is for your safety, so
This is for your safety, so
please be sure to take care
please be sure to take care
of your lead.
of your lead.

53. RADIATION MONITORING
RADIATION MONITORING
METHODS
METHODS

54. DETECTION OF RADIATION ?
DETECTION OF RADIATION ?

55. PERSONAL MONITORING METHODS
PERSONAL MONITORING METHODS
(DOSIMETRY)
(DOSIMETRY)
 Small radiation detectors called dosimeters, which are worn on the person
 There are several types of dosimeters used in practice.
– Film badges
– Thermo-luminescent dosimeters
– Optically stimulated luminescent dosimeters
– Direct reading dosimeters
 Dosimetry does not protect you from radiation.
Whole Body
Badge
Ring Badge

56.  According to Niklason et al. the effective radiation dose can be
estimated based on two dosimeter readings, one reading being a
dose measurement value under the lead apron and the other
being a measurement from over the lead apron or thyroid shield.
 Shook and Gross have recommended that every anaesthetist
involved in patient care in cardiac catheterization laboratories
should wear a dosimeter to track cumulative radiation exposure.
 Vano et al. stated that poor compliance with radiation badge
policies was one of the main problems in many interventional
cardiology services, and resulted in under-reporting of exposure.
PERSONAL MONITORING METHODS
PERSONAL MONITORING METHODS
(DOSIMETRY)
(DOSIMETRY)

57. DOSIMETRY BADGES
DOSIMETRY BADGES
If single dosimetry badge, wear
it outside the lead apron at
collar level.
If two badges, wear the “collar
badge” outside the lead apron,
and wear the “body badge”
underneath the lead apron at
chest level

58. SUMMARY
SUMMARY
 Current trends towards increased diagnostic and therapeutic uses of ionizing
radiation show no signs of abating. As such anaesthesiologists may expect to
spend more time working in centres using ionizing radiation.
 Anaesthesiologists must understand the basic concepts of radiation safety
 Even low levels of exposure are not inconsequential and the resultant cellular
injuries are cumulative and permanent
 Try all means to reduce the exposure doses to achieve ‘as low as reasonably
achievable’
 Know your equipment and make sure that fluoroscopy equipment is properly
functioning and periodically tested and maintained
 Use a lead apron that provides at least 0.25 mm lead equivalence on the back
and with overlapping 0.25 mm on the front (0.25 mm + 0.25 mm = 0.5 mm),
thyroid sheild and lead eye glasses.

59.  Use protective shields (mounted shields/flaps, ceiling suspended screens as
applicable)
 Keep hands out of the primary beam unless unavoidable for clinical reasons
 Stand in the correct place: whenever possible on the side of the detector and
opposite the X ray tube rather than near the X ray tube.
 Keep your knowledge of radiation protection issues up-to-date
 Address your questions to appropriate radiation protection specialists
 Always wear your personal radiation monitoring badge(s) and use them in the
right manner
 All actions to reduce patient dose will also reduce staff dose.
SUMMARY
SUMMARY

61. THE END
THE END